Rickard et al.

BMC Medicine 2010, 8:53

http://www.biomedcentral.com/1741-7015/8/53

RESEARCH ARTICLE Open Access

Routine resite of peripheral intravenous devices

every 3 days did not reduce complications
compared with clinically indicated resite:
a randomised controlled trial
Claire M Rickard1*, Damhnat McCann2, Jane Munnings3, Matthew R McGrail4

Abstract
Background: Peripheral intravenous device (IVD) complications were traditionally thought to be reduced by
limiting dwell time. Current recommendations are to resite IVDs by 96 hours with the exception of children and
patients with poor veins. Recent evidence suggests routine resite is unnecessary, at least if devices are inserted by
a specialised IV team. The aim of this study was to compare the impact of peripheral IVD ‘routine resite’ with
‘removal on clinical indication’ on IVD complications in a general hospital without an IV team.
Methods: A randomised, controlled trial was conducted in a regional teaching hospital. After ethics approval, 362
patients (603 IVDs) were randomised to have IVDs replaced on clinical indication (185 patients) or routine change
every 3 days (177 patients). IVDs were inserted and managed by the general hospital medical and nursing staff;
there was no IV team. The primary endpoint was a composite of IVD complications: phlebitis, infiltration, occlusion,
accidental removal, local infection, and device-related bloodstream infection.
Results: IVD complication rates were 68 per 1,000 IVD days (clinically indicated) and 66 per 1,000 IVD days (routine
replacement) (P = 0.86; HR 1.03; 95% CI, 0.74-1.43). Time to first complication per patient did not differ between
groups (KM with log rank, P = 0.53). There were no local infections or IVD-related bloodstream infections in either
group. IV therapy duration did not differ between groups (P = 0.22), but more (P = 0.004) IVDs were placed per
patient in the routine replacement (mean, 1.8) than the clinical indication group (mean, 1.5), with significantly
higher hospital costs per patient (P < 0.001).
Conclusions: Resite on clinical indication would allow one in two patients to have a single cannula per course of
IV treatment, as opposed to one in five patients managed with routine resite; overall complication rates appear
similar. Clinically indicated resite would achieve savings in equipment, staff time and patient discomfort. There is
growing evidence to support the extended use of peripheral IVDs with removal only on clinical indication.
Registration number: Australian New Zealand Clinical Trials Registry (ANZCTR) Number ACTRN12608000421336.

Background and nutrition but are not without complications. Serious

Peripheral intravenous device (IVD) insertion is the most
commonly performed invasive procedure in hospitalised
patients, with an estimated 150 million peripheral intra-
venous devices placed each year in North America alone
[1]. IVDs are vital for delivery of hydration, medicines
* Correspondence: c.rickard@griffith.edu.au
1
Research Centre for Clinical and Community Practice Innovation, Griffith
University, 170 Kessels Rd, Nathan Qld 4111, Australia
Full list of author information is available at the end of the article
adverse outcomes are fortunately rare, with IVD-related
bloodstream infection reported in a recent meta-analysis
of 110 studies to occur in 0.1% of devices and 0.5 per
1,000 device days [2]. IVD treatment is more frequently
interrupted by phlebitis, an irritation of the vein charac-
terised by pain, tenderness on palpation, erythema,
warmth, swelling, induration or palpable cord (thrombo-
sis) of the cannulated vein; diagnostic algorithms usually
require two or more of these conditions [3-5]. Phlebitis is

© 2010 Rickard et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons
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Rickard et al. BMC Medicine 2010, 8:53
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in almost all cases a biochemical reaction to the mechan-
ical irritation by the presence of the IVD and associated
infusate [3], although phlebitis symptoms such as
erythema may be misperceived as indicative of an infec-
tion. In fact, there is not a high correlation between phle-
bitis and device infection, and the Centers for Disease
Control (CDC) states that infection is rarely associated
with peripheral, as opposed to central, venous devices
[3,6,7]. Fluid infiltration or ‘tissuing’ of devices is another
common IVD complication which may also reflect the
inflammatory (phlebitic) response of the vein, rather than
simple misplacement of the device tip [8].
Early cohort studies noted an association between
increased device time in situ and phlebitis [9,10]. This
association was responded to with policies for routine
device removal. Recommended timelines for routine
resite have been extended over the past three decades
from 24, to 48, then to 72 hours. Currently, 72- to 96-
hour resite is recommended to reduce phlebitis by the
CDC’s 2002 Guidelines for the Prevention of Intravascu-
lar Device Infection, with the exemption that this is not
required in children or those with poor veins [7]. Such
policies cause increased workload in hospitals, where
the task of removing and replacing well-functioning
IVDs generally falls to busy nursing and junior medical
staff. In addition, few patients welcome the prospect of
additional venipuncture.
Despite the general clinical acceptance of routine IVD
replacement as a phlebitis and infection prevention mea-
sure, it has not been supported by recent data. It may be
that the risk of complications during the entire IVD
treatment episode is similar, regardless of whether mul-
tiple short-dwell or fewer longer-dwell IVDs are used
over this time. Three small (n = 47-60) randomised,
controlled trials (RCTs) suggested routine replacement
at 12, 24 or 48 hours may reduce phlebitis compared to
resite on clinical indication, although a systematic
review for the Swedish Council on Technology Assess-
ment in Healthcare assessed these as low- to medium-
quality studies providing ‘limited scientific evidence’
[11-14]. More recently, two well-conducted RCTs found
no evidence of effect when comparing IVD replacement
every 3 days with replacement only on clinical indica-
tion for medical and surgical inpatients [15,16]. The lar-
gest of these studies reported findings from 755 general
medical and surgical patients with 1,428 IVDs and
found a 5% difference in combined phlebitis and infiltra-
tion rates per patient (38% clinically indicated resite,
33% routine resite), suggesting a potential small clinical
benefit of 3-day resite [15]. However, this difference was
not statistically significant (RR 1.15; 95% CI, 0.95-1.40)
and disappeared when overall cannulation time was con-
sidered (59.8/1,000 IVD days clinically indicated resite,
60.9/1,000 IVD days routine resite; RR 0.98; 95% CI
Page 2 of 10
0.78-1.24) [15]. In addition, no clinically important or
statistically significant differences were observed in the
secondary endpoints of phlebitis, infiltration, occlusion,
local infection or suspected bloodstream infection rates
between study groups [15]. Another recent RCT in the
‘hospital in the home’ community setting also found no
important clinical or statistically significant difference in
phlebitis, occlusion or bloodstream infection rates in
316 patients when resite every 3 days was compared
with clinically indicated resite [17]. A 2010 Cochrane
Collaboration review concluded there was ‘no conclusive
evidence of benefit’ of routine IVD resite and suggested
organisations could consider adopting a resite on clinical
indication policy [18]. There is growing evidence that
routine IVD replacement may be ineffective, although
caution has been urged in light of the large number
(74% in both groups in the largest study to date) of
reported devices inserted by a specialised IV team, a fac-
tor known to reduce complications [19].
Device insertion (and reinsertion) is unpleasant for
patients, requires skilled and available clinical staff, and
has associated costs for the health sector. If replacement
only on clinical indication is safe and effective, this
would have important benefits for patients and the
health system. We report a RCT of 3-day routine IVD
resite versus clinically indicated replacement in a medi-
cal-surgical hospital where IVDs were inserted by the
general medical and nursing staff; the insitution did not
have a specialised IV service.
Methods
Aim
The aim of the study was to compare the impact of 3-
day routine resite, with clinically indicated resite, on
peripheral IVD complications.
Design
Open (nonblinded), parallel group RCT.
Ethics
The study was approved by the Tasmanian State Human
Research Ethics Committee. Written informed consent
was obtained prospectively from all participants.
Setting and sample
The study was undertaken at a large regional teaching
hospital in Australia which functions as the tertiary refer-
ral centre for the northern half of the State of Tasmania.
The hospital has more than 32,000 separations per
annum, with a spectrum of medical and surgical special-
ties. Eligible patients were at least 18 years of age and
scheduled or expected to have a peripheral IVD indwel-
ling for at least 4 days, and they gave written informed
consent. Exclusion criteria were immunosuppression,
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current bloodstream infection or an IVD already in situ
for >48 hours. IVDs were inserted and cared for by the
general nursing and medical staff; there was no special IV
team or service.
Sample Size
Sample size calculations were performed using PASS
2008 (Version 8.0.8; Kaysville, UT) to detect a change in
rates by 30% (from 36% to 25%, two-tailed a = 0.05,
90% power) on the basis of the complication rates of
routinely resited IVs in a previous study [16]. Although
this indicated that n = 378 per group (total 756) were
required, the study was ceased early (total n = 606 IVs)
because all investigators left the employment of the
institution. Consequently, study power was reduced, but
remained over 80% (required minimum n = 282 per
group).
Recruitment
All adult patients admitted to the inpatient acute medi-
cal and surgical wards of the study hospital were
screened by a full-time research nurse. This excluded
paediatric, day-surgery, mental health, obstetric, critical
care and dialysis units.
Study procedures
Patients were randomly assigned (computer generated)
in a 1:1 allocation ratio to either the ‘routine replace-
ment’ (control) or ‘clinically indicated replacement’
(intervention) group. Assignment was concealed until
randomisation by use of a telephone service. A tag was
placed on the insertion site indicating the study group.
All devices for the patient were managed as per rando-
mised group. The intervention group did not have their
IVD resited unless clinically indicated. This decision was
made by the treating clinician (not the investigators),
who ordered IVD resite if the device failed or phlebitis
occurred and ongoing IV treatment was required. The
control group had a new device relocated to a different
site by the general medical or nursing staff every 3 days.
Control devices could also be removed at any stage by
the clinical staff if they were not required or if compli-
cations occurred. Clinical nursing and medical staff
undertook insertion and follow-up care of all IVDs as
per the CDC Guidelines [7].
Laboratory staff undertaking microbiological culture
assessments were blinded to the study group. Due to
the nature of the intervention, patients, research, and
clinical staff were unable to be blinded. However, the
investigators had no involvement in assessing or docu-
menting complications.
IVDs were assessed by the clinical nursing staff on
each nursing shift for complications as part of standard
clinical practice in the hospital. Times and dates of
Page 3 of 10
device insertion and removal were recorded along with
the reason for device removal and any protocol devia-
tions. A full-time research nurse collected data from the
hospital chart and sought clarification from patients and
clinical staff if necessary. Microbiological investigations
(device tip, blood cultures and site cultures) were per-
formed by the clinical staff on clinical suspicion of infec-
tion by the treating clinician. Demographic and clinical
data were collected on age, sex, diagnosis at hospital
admission, phlebitis risk based on Tagar et al.’s classifi-
cation (low/medium/high risk) [20], past history of phle-
bitis, any comorbidities requiring active medical
treatment (e.g., type 2 diabetes or congestive heart fail-
ure), haemoglobin, concurrent infection at other sites,
antibiotic therapy, type of surgery, type of infusate and
any additives (and their level of irritability), vein and
skin quality assessment, size of device, insertion site,
health professional inserting the device, and setting for
insertion, presence of other vascular devices, wound
drains and urinary catheters. Vein quality was assessed
as good (vein easy to visualise and easy to palpate with
tourniquet on), fair (not easily visible but can palpate
with tourniquet), or poor (veins small, scarred or diffi-
cult to palpate with tourniquet; may require heat pack
to aid vasodilation). Skin quality was assessed as good
(healthy, well hydrated, elastic), fair (mildly dehydrated,
reduced elasticity), or poor (papery, dehydrated, or
reduced elasticity).
Analytic Approach
The primary outcome was a composite measure of any
complication causing unplanned cannula removal prior
to completion of IV treatment. The composite included
phlebitis, infiltration, occlusion, accidental removal, local
infection, and IV device-related bloodstream infection
(IVD-BSI). These were also analysed individually as sec-
ondary endpoints. A composite measure was chosen due
to the low rates of these conditions individually and to
the assumption that they are comparable measures of
‘infusion failure’; that is, the device can no longer be
used to deliver treatment. This approach has been used
in previous studies on the topic [15-17]. Phlebitis was
defined as two or more of pain, erythema, purulence,
streak formation, or a palpable venous cord [3]. Local
infection IVD-BSI (bacteremia/fungemia with at least
one positive blood culture obtained from a peripheral
vein, clinical manifestations of infection, and no appar-
ent source for the bloodstream infection (BSI) except
the device with or without positive tip or entry site
swab culture) were defined using CDC criteria [7].
Other secondary outcomes were time in situ (hours of
catheterisation from insertion to removal, both per
patient and per device) [7]; IVDs per patient (number of
peripheral devices inserted to complete the course of
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treatment) [7]; costs (calculations based on 20 minutes
nursing or medical insertion time at relevant rates [15],
plus the cost of the required equipment (cannula, inser-
tion pack including dressing and solution, gloves, saline,
syringe, extension tubing and starter pack for all plus
fluid bag, tubing and secondary tubing for medication
administration for those patients requiring this) for
insertions, nursing time and equipment to routinely
remove IVDs that were otherwise functional, and the
costs of treating any complications that occurred (e.g.,
IVD-BSI). Cost calculations were undertaken from the
viewpoint of the hospital using negotiated wage costs
and purchasing agreements for government hospitals in
the State of Tasmania. Costs would be similar for other
Australian hospitals.
All randomised patients were analysed by intention to
treat. Each patient was randomised once and could have
multiple IVDs, with subsequent IVD resites managed as
per the randomised group. Relative incidence complica-
tion rates per 1,000 IVD days and 95% confidence inter-
vals were calculated to summarise the impact of
clinically indicated replacement relative to 3-day repla-
cement. Kaplan-Meier survival curves were drawn to
compare time to first IVD complication between
patients in the two study groups. To assess for any
potential impact of protocol violations, a per protocol
analysis was also undertaken. All clinical and demo-
graphic variables were subjected to univariate testing
against the primary endpoint to guide selection of possi-
ble covariates for the multivariable model. Cox propor-
tional hazards regression modelling was used to
examine the impact of age, gender, oncology status,
number of comorbidities (nil, one, two, or more than
two), IV gauge, site, vein quality, skin quality, oral anti-
biotics, IV antibiotics, wound drain, inserter occupation,
initial versus subsequent IVDs, phlebitis in a preceeding
IVD, haemoglobin level, parenteral nutrition, continuous
versus intermittent infusion, patient risk category and
study group on the outcome of time to complication
events using an additive model [3,5,7,20-25]. In addition,
to adjust for any inherent correlations or codependen-
cies in the failure times of IVDs (i.e., same patient mul-
tiple failure-time data) within the Cox model, we also
used the Prentice-Williams-Peterson conditional risk-set
method [26]. The Mann-Whitney test was used to com-
pare various secondary outcomes between study groups.
Cost differences were calculated using arithmetic means
and the t-test [27]. P values <0.05 were considered sig-
nificant. All statistical data were entered and analysed
using SPSS (Version 15.0; Chicago, IL) and Stata (Ver-
sion 8.2; College Station, TX).
Page 4 of 10
Results
Sample
Over a 10-month period, 1,954 patients were screened
for eligibility. Of these, 788 were eligible, with 362 (46%)
recruited into the study. The most frequent exclusion
criterion was altered mental state that precluded consid-
eration of consent as assessed by the research nurse.
Altered mental state was generally related to older med-
ical patients and the immediate postoperative phase for
surgical patients. Reasons for exclusion are shown in
Figure 1. The 362 patients were randomised into either
the routine change group (n = 177 participants, 323
devices) or the clinically indicated replacement group (n
= 185 participants, 280 devices). In total 50,173 IVD
hours were studied (routine change group 23,288 hours,
clinically indicated group 26,885 hours). More patients
in the routine change group had an active infection
(53% vs. 44%) and were receiving IV antibiotics (73% vs.
64%). However, as shown in Tables 1 and 2, the two
groups were generally comparable at baseline for
patient- and cannula-related factors.
Effect of intervention on primary outcome
Outcome data were available for all patients. Table 3
shows the rates of primary and secondary outcomes.
Differences in complication rates between groups were
not significantly different (routine replacement 66.0 per
1,000 IVD days; clinical replacement 67.8 per 1,000 IVD
days; HR 1.03; 95% CI, 0.74-1.43; P = 0.86). As shown
in Figure 2, the time to first complication per patient
was also not significantly different between groups
(Kaplan Meier [KM] with log rank P = 0.53). On crude
rate per IVD, the catheters replaced on clinical indica-
tion had higher complication rates (110/280 or 39% vs.
91/323 or 28%; P = 0.004). However, total complication
rates per patient (to deliver the course of IV therapy)
were not significantly different (P = 0.39) between clini-
cally indicated (76/185, 41%) and routine resite patients
(64/177, 36%).
Patient- and device-related variables considered in the
multivariable model were older age, number of comor-
bidities (nil, one, two or more than two), smaller can-
nula size, poor skin or vein integrity, IV antibiotics,
insertion by medical staff and study group. None of
these were found to be statistically significant. The final
Cox proportional hazards model after adjusting for time
found study group was not a significant factor (HR 1.02;
95% CI, 0.77-1.36; P = 0.89). Variance-adjustment test-
ing for potential multiple-failures per patient (cannula
data) found no inconsistency in significant results com-
pared to the main Cox model.
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Figure 1 Participant flowchart.
Protocol compliance
Compliance with the study intervention was achieved in
78% (251 of 323) of routinely replaced IVDs removed at
Day 3 and 100% (280 of 280) of IVDs resited on clinical
indication. Noncompliance in the routine resite group
was generally related to high staff workloads on that day
or to staff’s perception that the patient was soon to be
discharged or have therapy completed, and so the IVD
remained in situ beyond Day 3. A per protocol analysis
was performed including only those patients in the rou-
tine replacement group whose IVDs were all actually
removed by 96 hours (n = 251). This found no signifi-
cant difference (KM with log rank P = 0.16) in the rate
of complications between groups (routine replacement
92 per 1,000 IVD days vs. clinically indicated 68 per
1,000 IVD days).
Effect of intervention on secondary outcomes
There was no statistically significant difference in group
outcomes for any phlebitis (P = 0.34), infiltration
(P = 0.57), occlusion (P = 0.75), or accidental removal
(P = 0.43). No cases of local infection or IVD-related
bloodstream infection occurred in either group.
For overall IVD therapy (total cannulation time per
patient for all devices), clinically indicated devices had a
Page 5 of 10
median therapy of 120 hours (quartiles 86.5 and
172.5 hours), and those replaced routinely had median
therapy of 113 hours (quartiles 72 and 172 hours)
(P = 0.21). For individual IVD dwell times, the clinically
indicated group devices had a median dwell time of 85
hours (quartiles 51 and 121 hours), and those replaced
routinely had a median dwell time of 71 hours (quartiles
48 and 90 hours) (P < 0.001). The maximum IVD dwell
time was 1,023 hours (43 days) in the clinical replace-
ment group, and this cannula was still working well on
removal for completion of therapy.
The overall number of IVDs per patient was signifi-
cantly less (P = 0.004) for those replaced on clinical
indication (mean 1.5, SD 0.8, median 1, quartiles 1 and
2) than for those routinely replaced (mean 1.8, SD 1.1,
median 1, quartiles 1 and 2). A total of 22% of patients
in the routinely replaced group had three or more IVDs
compared with 9% in the clinical indication group. A
total of 82 (28%) IVDs in the routine replacement group
were resited after 3 days despite functioning well and
ongoing treatment being required. (The remainder
removed at this time were no longer required and so
not resited, or infusion failure had already occurred.)
Mean hospital costs per patient for the course of IV
therapy were significantly higher (P < 0.001) for those
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Table 1 Baseline characteristics of study participants

Variable 3-Day Routine Change Group Clinically Indicated Change Group
(n = 177) (n = 185)
Sex - Male, n (%) 96 (54%) 103 (56%)
Age, mean (SD) 65.1 (17.3) 62.7 (15.4)
Reason for admission, n (%)
• Gastrointestinal 46 (26%) 52 (28%)
• Respiratory 37 (21%) 34 (18%)
• Oncology 21 (12%) 21 (11%)
• Orthopaedic 16 (9%) 22 (12%)
• Cardiac 10 (6%) 10 (5%)
• Neurological 9 (5%) 10 (5%)
• Vascular 7 (4%) 7 (4%)
• Renal 16 (9%) 9 (5%)
• Other 15 (8%) 20 (11%)
Number of comorbidities, n (%)
• None 6 (3.4%) 10 (5.4%)
•1 22 (12.4%) 21 (11.4%)
•2 44 (24.9%) 54 (29.2%)
• >2 105 (59.3%) 100 (54.1%)
Type of surgery, n (%)
• Nil 124 (70%) 132 (71%)
• Gastrointestinal 22 (12%) 22 (12%)
• Orthopaedic 8 (5%) 15 (8%)
• Other 23 (13%) 16 (9%)
Most recent Hb - Mean (SD) 124.8 (23.2) 126.2 (21.9)

managed with routine resite (mean $55.42, SD $35.26)
compared with resite on clinical indication (mean
$43.35, SD $26.78).
Discussion
The finding that 3-day routine resite was not an effec-
tive intervention was consistent across the intention-to-
treat primary analysis and the per protocol analysis.
There remained no effect when events were expressed
per patient or per 1,000 IVD days. Neither composite
nor individual complication rates differed between
groups, and there were no cases of local or device-
related bloodstream infection. It appears safe and practi-
cal to leave IVDs in situ as long as they are functioning
well and are still needed for clinical treatments.
All IVDs will fail eventually, but this study shows that
artificially shortening the lifespan of individual catheters
does not reduce the overall complication rates over the
course of therapy. Our results indicate that the average
duration of IV therapy is 5-6 days and that many cathe-
ters can remain complication-free for this period. If
catheters are not routinely resited, the median dwell
time would remain within the 72-96 hours recom-
mended by the CDC, but about 10% would remain
in situ for longer (in this study up to 43 days with no
complications). Our data show that a policy of resite on
clinical indication would mean that one of every two
patients would need a single cannula to receive treat-
ment, whereas a 3-day change policy would result in
only one in five patients having this scenario, with the
rest requiring multiple cannulations and therefore addi-
tional pain and inconvenience.
The results are consistent with the findings of recent
RCTs in both hospitals and the community that have
found no benefit in routinely resiting IVDs every 3 days
[15-17]. In these studies, many cannulae were inserted
by an expert IVD team [15-17], which may have mini-
mised complications in both groups [19]. Our study
confirms and extends these findings into the general
medical/surgical setting without an IV team where IVDs
were inserted by a variety of nursing and medical staff.
Data from this study were included in a 2010 Cochrane
Collaboration systematic review and meta-analysis on
the topic [18]. This review included six trials (n = 3,455)
and reported no clinically important or statistically sig-
nificant difference in catheter-related bloodstream infec-
tion or phlebitis between IVDs that were routinely
resited (at 48-96 hours) or resited on clinical indication,
yet there were significantly lower costs in the group res-
ited on clinical indication [18].
The belief that routine resite of IVDs will prevent
complications appears to stem from early observational
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Table 2 Baseline infusion-related characteristics of study devices

Variable 3-Day Routine Change Group (n = 323), Clinically Indicated Change Group (n = 280),
n (%) n (%)
IV cannula gauge
• 22 43 (13%) 46 (16%)
• 20 241 (75%) 201 (72%)
• 18 27 (12%) 30 (11%)
• Other 2 (1%) 3 (1%)
Vein assessment
• Good 143 (44.3%) 107 (38.2%)
• Fair 160 (49.5%) 144 (51.4%)
• Poor 20 (6.2%) 29 (10.4%)
Skin integrity
• Good 138 (43%) 104 (37%)
• Fair 178 (55%) 164 (59%)
• Poor 7 (2%) 12 (4%)
Past history of phlebitis 2 (0.6%) 4 (1.4%)
Insertion site
• Hand 206 (64%) 187 (67%)
• Forearm 59 (18%) 49 (18%)
• Cubital fossa 51 (16%) 38 (14%)
• Other 7 (2%) 6 (2%)
Receiving infusate 241 (75%) 215 (77%)
pH of infusate - Mean (SD) 6.0 (0.5) 6.0 (0.4)
Receiving oral antibiotics 24 (7%) 24 (9%)
Receiving IV antibiotics 236 (73%) 176 (63%)
pH of IV antibiotics - Mean (SD) 6.9 (1.1) 6.9 (1.3)
Receiving other IV meds 190 (59%) 179 (64%)
pH of other IV meds - Mean (SD) 5.6 (2.6) 6.0 (2.8)
Wound drain 50 (16%) 40 (14%)
Urinary catheter 55 (17%) 41 (15%)
Other vascular device 26 (8%) 24 (9%)
Inserted by
• Junior doctor 232 (72%) 207 (74%)
• Registered Nurse 67 (21%) 57 (20%)
• Senior doctor 24 (7%) 16 (6%)
Where inserted
• Ward 216 (67%) 188 (67%)
• Emergency department 74 (23%) 70 (25%)
• Other 33 (10%) 22 (8%)
Current infection (site)
• Respiratory 97 (30%) 49 (18%)
• Urinary 24 (7%) 19 (7%)
• Wound 16 (5%) 15 (5%)
• Other 29 (9%) 37 (13%)
• >1 site 5 (2%) 4 (1%)
N/A (none) 152 (47%) 156 (56%)
Risk of phlebitis (Tagar scale)
• Low 174 (54%) 144 (51%)
• Medium 149 (46%) 136 (49%)
• High 0 0
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Table 3 Effect of intervention on primary and secondary endpoints

Outcomes 3-Day Routine Change Clinically Indicated Change Group RR (95% CI),
Group (n = 185) P Value
(n = 177)
Primary:
IVD complications per patient, n (%) 64 (36%) 76 (41%) RR 1.14 (0.88, 1.47),
p = 0.39
IVD complications per 1000 IVD days 66.0 67.8 HR 1.03 (0.74, 1.43),
(95% CI 49.8, 82.1) (95% CI 52.6, 83.1) p = 0.86
Secondary:
Phlebitis, n (%) 12 (7%) 18 (10%) RR 1.44 (0.71, 2.89), p = 0.34
Infiltration, n (%) 53 (30%) 61 (33%) RR 1.10 (0.81, 1.49), p = 0.57
Occlusion, n (%) 5 (3%) 4 (2%) RR 0.77 (0.21, 2.80), p = 0.75
Accidental removal, n (%) 11 (6%) 16 (9%) RR 1.39 (0.66, 2.92), p = 0.43
Local infection 0 0 -
IVD-related BSI, n (%) 0 0 -
IVD costs per patient, $55.42 ($35.26) $43.35 Mean difference
AUD$ mean (SD) ($26.78) $12.07 (95%CI $5.57, $18.56), p < 0.001

studies that noted longer-dwelling IVDs had more com-
plications than shorter-dwelling IVDs [9,10]. This is
intuitively true, given, for example, that an IVD in situ
for 6 days has twice the time exposure of risk than an
IVD in situ for 3 days. However, this does not prove
that two sequentially inserted IVDs (in the same
patient), both used for 3 days, have a combined lower
risk over time than the 6-day dwell device. Indeed, this
and other recent trials strongly suggest that the risk for
the patient over the 6-day period is similar. Well-
designed cohort studies with modern catheter materials
suggest that the daily risk of phlebitis is relatively stable
after the first 24 or 48 hours [3,21,28-31]. The peak in
phlebitis between 24 and 48 hours is likely associated
with the time taken by the body to mount a biological
response after the instigation of therapy; those most
likely to develop phlebitis will do so at this time.
The results support the extension of the use of per-
ipheral IVDs beyond the 72-96 hours currently recom-
mended by the CDC [7]. There is incongruity in the

Figure 2 Kaplan-Meier survival curve of time to first intravenous device complication per patient (log rank, P = 0.53).
Rickard et al. BMC Medicine 2010, 8:53
http://www.biomedcentral.com/1741-7015/8/53
CDC recommendations; they recommend not to routi-
nely resite IVDs in children or in those with limited
venous access. If it is safe in these populations, it is
unclear why it would be necessary to routinely resite
adults or those with better veins. Higher-risk cannulae
such as central venous devices are no longer recom-
mended by the CDC for routine replacement, because
trials showed this was not of benefit [7]. Our study also
confirms that the CDC guidelines are not always com-
plied with; one fifth of IVDs in the routine change
group were not replaced by this time. However, the per
protocol analysis showed that the intervention remained
ineffective even for those who truly had their IVDs res-
ited every 3 days.
Limitations of the study included a 9% higher fre-
quency of IV antibiotics and concurrent infection in the
routine resite group. This may have put the group at
higher risk due to vein irritation, or conversely it pro-
tected against bacterial entry. Neither variable was sig-
nificant in the multivariable model. The unblinded study
design was unavoidable, but also a limitation. Our use
of clear outcome measures, a full-time research nurse
and laboratory staff blinded to culture assessments
should have reduced the risk for potential bias. Resource
constraints prematurely ended recruitment, thus redu-
cing the anticipated power of the study from 90% to
80%.
Routine IVD resite involves pain for patients, staff
procedural time, equipment costs and environmental
waste. Contemporary evidence suggests the current pol-
icy for routine resite by 72-96 hours is ineffective and
should be replaced with a ‘resite on clinical indication’
policy. It remains imperative that clinical staff monitor
IVDs closely and that a daily review of the need for con-
tinuing therapy be made, with cessation as soon as pos-
sible; the only no-risk IVD is no IVD. Of the 4.3 million
acute hospital admissions in Australia each year (exclud-
ing day cases), over half have IV treatment [15,32]. Con-
servatively, if even 2 million courses of IV therapy were
managed with clinically indicated rather than routine
resite, this would save the unnecessary insertion of
approximately 660,000 IVDs and free 280,000 hours of
staff insertion time. Assuming our costs are similar to
those in other Australian hospitals, a change to resite on
clinical indication would save approximately AUD$24
million nationally each year.
Conclusions
Although larger, multisite trials are required, evidence to
date suggests that routine resite of peripheral IVDs
increases patient discomfort and healthcare costs, but
does not reduce IVD complications as has traditionally
been thought.
Page 9 of 10
Acknowledgements
The authors wish to thank the participants and the nursing and medical
staff at Launceston General Hospital who supported the study, in particular
the Department of Medicine. The authors gratefully acknowledge the
support of a competitive project grant from the Clifford Craig Medical
Research Trust, Launceston, Tasmania. The funding body was not involved in
the design, undertaking or publication of the study. Further financial support
of the study came from the Launceston General Hospital, University of
Tasmania, Monash University and Griffith University. We thank the BMC
reviewers for their constructive comments on the manuscript.
Author details
1
Research Centre for Clinical and Community Practice Innovation, Griffith
University, 170 Kessels Rd, Nathan Qld 4111, Australia. 2School of Nursing
and Midwifery, University of Tasmania, Newnham Drive, Launceston Tas
7250, Australia. 3St Luke’s Hospital, Calvary Tasmania, Launceston Tas 7250,
Australia. 4Gippsland Medical School, Monash University, Northways Rd,
Churchill Vic 3842, Australia.
Authors’ contributions
CMR designed the study, applied for funding and drafted the manuscript.
DM participated in study design and manuscript preparation, and managed
the study. JM recruited patients, ensured protocol integrity and collected
data. MRM undertook statistical analyses and assisted with drafting the
manuscript. All authors read and approved the final manuscript.
Authors’ information
CMR, PhD is Professor, Research Centre for Clinical and Community Practice
Innovation, Griffith University, Australia. DM holds a Masters by Research and
is Senior Lecturer, University of Tasmania, Australia. JM is an RN and Nurse
Unit Manager, Calvary Tasmania, Australia. MRM is a PhD qualified
Biostatistician, Gippsland Medical School, Monash University, Australia.
Competing interests
The authors declare that they have no competing interests.
Received: 13 April 2010 Accepted: 10 September 2010
Published: 10 September 2010
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